Wiki Sutter Health legal case - coding community implications?

[janegammonaguirre]

A recent settlement was reached for Sutter Health care: "The settlement announced today resolves allegations that Sutter and its affiliates submitted unsupported diagnosis codes for certain patient encounters of beneficiaries under their care. These unsupported diagnosis scores inflated the risk scores of these beneficiaries, resulting in the MAO plans being overpaid." (quote from link below)

The detail of what 'unsupported' means is unclear in these two links describing the settlement, so it is difficult to draw conclusions. I wondered if AAPC has insight on the particulars.

https://www.modernhealthcare.com/go...ding-allegations?utm_source=modern-healthcare am&utm_medium=email&utm_campaign=20190415&utm_content=article2-headline
https://www.justice.gov/opa/pr/medi...settle-alleged-overpayment-medicare-advantage​

diagnosis codes, diagnosis coding

 

[meghanhannus]

Hello janegammonaguirre,

I believe what this means is that the provider's documentation did not support the ICD-10-CM diagnosis codes reported to be calculated correctly with the risk adjustment model. In other words it could be looked at as "up-coding"....so for example the provider's documentation in the medical record supported a patient with controlled DMII but the ICD-10-CM diagnosis reported to MCR Advantage was that the patient had more severe DMII with complications to inflate the risk adjustment score (and payment).

diagnosis codes, diagnosis coding